55YO Man Died After Stretcher Collapsed While He Was Being Transferred Between Hospitals; Had Traumatic Brain Injury

Anyone makes mistakes—it is simply part of human nature.

Unfortunately, not all mistakes can be forgiven easily, especially when they lead to fatal consequences that take away someone’s life.

Man Dies After Head Injury Following Stretcher Collapse

Mr Razib Bahrom, 55, was sent to Khoo Teck Puat Hospital (KTPH) at 9:00pm on 17 June 2018 as he had experienced worsening chest pains.

Diagnosis showed that he had suffered from a heart attack, also known as acute myocardial infarction, and received procedural treatment for it on that night, but to no avail.

The National Heart Centre Singapore (NHCS) had to send a medical team over to assist Mr Razib’s heart functions, which was done by inserting a extracorporeal membrane oxygenation (ECMO) machine that they brought over.

At about 1:25am, Mr Razib was transferred from KTPH to NHCS via an ambulance.

However, the ECMO machine started beeping on the way, indicating that its battery was low.

The medical staff present tried to plug the charging wire of the machine into the ambulance’s socket, but there wasn’t any power supply and the machine couldn’t be charged in the end.

It managed to hold out until the ambulance arrived at the Singapore General Hospital (SGH) where Mr Razib was transferred out at about 1:40am.

The Stretcher’s Legs Gave Way

Mr Razib had a stable pulse and condition at the time when the ambulance driver began to unload the stretcher carrying him.

However, the stretcher’s collapsible legs failed to deploy completely at that moment, causing the top part of the stretcher which held his head to fall towards the ground.

Mr Razib’s head did not make contact with the ground and he was firmly secured on it.

The ECMO machine had died for about five minutes during this time until it was powered up again at the critical care area. At about 2:15am, he was moved to the cardiothoracic surgery intensive care unit.

They kept an eye on him and assessed him at regular intervals, but discovered the possibility of an underlying neurological condition when his pupils were dilated and fixed at about 7:30am.

Urgent CT scans showed bleeding in his brain, which had swelled significantly and suffered damages.

Since the chances of him improving were low and his condition was expected to deteriorate, they decided to take him off the ECMO support at about 11:15am after discussing it with his family.

Unfortunately, Mr Razib died within that same hour, with the cause of death being an acute heart attack and acute subdural haemorrhage, meaning there was bleeding in his brain.

Why Did the Stretcher Collapse?

When operating a stretcher, one has to pull it out a quarter of the way and lift it up before pulling it out further until three quarters of the way so that the stretcher’s legs could expand and click into place.

The ambulance driver had followed procedures up to the part where he pulled one quarter of the stretcher out, but asked for assistance as the man weighed 85kg and was too heavy.

After he gave the command to lift, those assisting him had done so, but the legs still failed to extend properly. The head end of the stretcher thus fell to the ground while the driver was still holding on to the other end.

KTPH’s designated ambulance porter was unable to join the staff in the transfer as the ambulance didn’t have enough space for him.

Prior bi-annual maintenance checks revealed nothing wrong with the stretcher, which had functioned as expected. The ambulance and equipment used were also adequate according to weekly maintenance reports.

Stretchers can hold up to about 120kg of weight.

Bleeding Was Mostly Caused By The Fall

Could Mr Razib really have been injured to that point even when his head didn’t hit the ground, though?

Yep, it’s totally possible, for it was the force and gravity of the fall itself that caused the bleeding.

According to a senior consultant neurosurgeon from Immanuel Centre for Neurosurgery, Dr John Thomas, the fall had contributed significantly of about 95% to the bleeding in Mr Razib’s head, although he couldn’t say that it was the only cause.

State Coroner Kamala Ponnampalam told the court of Dr Thomas’ explanation that “an 85kg man falling in a 45-degree arc from a height of about one metre would experience a fairly significant force even if he did not fall off the trolley.”

“Even a simple shake can tear something like a small vein without actually injuring the brain because the brain is connected to the skull by the veins,” she added.

Although SGH had taken appropriate steps to care for Mr Razib after the fall, the precipitation of the blood clot in his brain was apparently what “tipped everything over.”

Mr Razib’s daughter stated that she was unaware that patient transfers encompassed such risks, and that SGH failed to inform her of the ECMO running out of battery as well as the malfunctioning of the stretcher that caused the fall.

No foul play was suspected and the coroner informed them that it was difficult to predict whether Mr Razib might have made good recovery even without the fall as he was severely ill.

Mr Razib’s death was ruled as an “unfortunate medical misadventure” by the coroner, and she also advised hospitals to re-look their procedures to form specific guidelines on patient transfers in similar circumstances.

All necessary staff should also be accommodated for with the use of appropriate provisions such as larger ambulances or emergency vehicles.

The ECMO’s battery running out was also ruled as a near-miss event by medical experts, who held that it did not contribute to or cause Mr Razib’s death.

Suggestions were made for the battery to always be fully charged before a patient transfer, and for staff to have a fully charged spare battery on hand while on the road.

It remains unknown whether Mr Razib’s family will take further legal action.

The coroner also extended her condolences to his family for their loss.

It should be even more crucial for hospitals to remain alert and careful of any slip-ups that may occur due to a series of unfortunate events now.

Feature Image: Syda Productions / Shutterstock.com